The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?
Impaired perineal skin integrity
Protein-calorie malnutrition
Pain related to abdominal cramping
Fluid and electrolyte imbalance
The Correct Answer is D
A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.
Correct Answer is A
Explanation
A. Upper UTI refers to infections that affect the kidneys (pyelonephritis) and ureters. These infections are typically more serious and can lead to kidney damage if not treated promptly.
B. Lower UTI refers to infections that affect the bladder (cystitis) or urethra (urethritis), which are generally less severe than upper UTIs.
C. Urosepsis is a severe, systemic infection that results from a UTI that has spread to the bloodstream. It can occur with either upper or lower UTIs.
D. Uncomplicated UTI refers to a straightforward infection of the urinary tract, typically involving the bladder, in an otherwise healthy individual. It is not specifically related to the kidneys or ureters.
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